GSWO Health Information and Release Form

Girl Scouts of Western Ohio
HEALTH INFORMATION AND RELEASE FORM
To be completed and reviewed annually by parent/guardian or adult. This form should be kept with the troop/group records and accompany the troop/group leader on all troop/group activities. It is designed to provide the troop/group leader with the information needed to access medical care for your daughter. It should be reviewed and updated (as needed) when information changes.
Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Address:
City, State, Zip:
Troop #:
PART I: PARENT INFORMATION AND RELEASE
She is under the custodial care of:
Other
Mother/Guardian Name
Address (if different than girl):
Employer:
Occupation:
Phone (day):
Phone (evening):
Cell Phone:
Email:
example@example.com
Father/Guardian Name
Address (if different than girl):
Employer:
Occupation:
Phone (day):
Phone (evening):
Cell Phone:
Email:
example@example.com
PART II: EMERGENCY CONTACT AND RELEASE INFORMATION
In the event that I cannot be reached in an emergency, the following are authorized to act in my behalf:
Name:
Relationship to Participant:
Address
Address
Street Address Line 2
CityState
Zip
Home Phone:
Work Phone:
Cell Phone:
Name:
Relationship to Participant:
Address
Address
Street Address Line 2
CityState
Zip
Home Phone:
Work Phone:
Cell Phone:
ADDITIONAL RELEASE INFORMATION:
In addition to the above parent(s)/guardian(s) and emergency contacts, this participant may also be released to the following persons:
Name:
Relationship to Participant:
Name:
Relationship to Participant:
PART III: HEALTH CARE INFORMATION:
Physician’s Name:
Phone:
Address
Physician’s Address
Street Address Line 2
CityState
Zip
Dentist’s Name:
Phone:
Address
Dentist’s Address
Street Address Line 2
CityState
Zip

Rows	Year Primary Series Completed	Year of Last Booster
DTP (Diphtheria; Tetanus; Whooping Cough)
Hepatitis B
MMR (Measles/Mumps/Rubella)
Oral Polio
TD (Tetanus/Diphtheria)
Tuberculin Test (most recent) Result
Others:

Rows	Name	Being Taken for (Condition)	Dosage and Frequency
Medication 1
Medication 2
Medication 3

Girl Scouts of Western Ohio

HEALTH INFORMATION AND RELEASE FORM

PART I: PARENT INFORMATION AND RELEASE

PART II: EMERGENCY CONTACT AND RELEASE INFORMATION

ADDITIONAL RELEASE INFORMATION:

PART III: HEALTH CARE INFORMATION:

PART VI: IMMUNIZATION HISTORY

Immunization